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King v. Burwell: the more you try to challenge things, the more they stay the same

In the aftermath of the Supreme Court’s decision supporting the payment of subsidies by the federal government to eligible persons seeking insurance through the federal health insurance exchanges ("Exchanges") under the Affordable Care Act ("ACA"), many patients and providers alike are asking, "what does this Supreme Court decision mean for me?" The short answer: very little…

The reason is that this decision upholds the status quo. In King v. Burwell, the Justices reviewed the ACA provision that authorized the use of subsidies as means for providing assistance to those who could not afford to purchase insurance without financial assistance. The King v. Burwell upheld this portion of the ACA, holding that the federal government may provide subsidies to those who purchase insurance via the federal exchange.

Under the ACA, persons who are either unemployed or do not receive employer-sponsored insurance must purchase insurance on their own. The ACA provided for the creation of an online marketplace as a place to purchase this health insurance. Individual states were given the option of creating their own "healthcare exchange" platform, but when many did not do so, the federal government established its own exchange, accessible at healthcare.gov. Through this exchange, the federal government provided subsidies to those who could not afford to purchase insurance on the exchange without some form of financial assistance. The subsidies, and not the marketplace at large, were at issue in King v. Burwell.

In King v. Burwell, the Plaintiff argued that the ACA language requiring people to purchase their health insurance on an exchange "established by the State" invalidated the subsidies provided on the exchange established by the federal government. They claimed that the subsidies are not permissible because the federal government is not a "State."

However, the Supreme Court disagreed with the Plaintiff’s argument, holding 6-3 that the subsidies are valid and available for everyone purchasing insurance through an exchange, even the one created by the federal government. In the majority opinion, Chief Justice Roberts held that the underlying intent of the ACA was to make health insurance available to everyone that must purchase it on the exchange, and that the use of subsidies is an essential part of achieving this goal. Without subsidies, many individuals would be priced out of the insurance market. Therefore, it was imperative for the government to create a federal exchange with subsidies in those states where no state-run exchange was available. If not, the Court held, the ACA would fall victim to its own "death spiral," creating an environment in which premiums go up and enrollment goes down.

So what does this holding mean for everyday Americans? It means that things, for now, remain the same. The three components of the ACA have survived: (1) the Non-Discrimination rule, which prohibits insurance companies from overcharging or denying coverage to those with pre-existing conditions; (2) the individual mandate, which requires that every American have health insurance or pay a penalty; and (3) the subsidies made available to those who do not have insurance through an employer. Low-income Americans will still be able to receive a subsidy to purchase insurance on the federal exchange as they do in state-sponsored exchanges. Regardless of the dissent’s claim that the ACA should now be called SCOTUScare, the reality for patients and practitioners is that the ACA, whatever it comes to be called in later years, is here to stay.